Request New Certificate Request New Certificate If you have not received your certificate of completion or you need another copy of your certificate, please use this form to request a new certificate. Thank You. Student's Legal Name* First Middle Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Driver's License # Phone*Current Mailing Address* Street Address City State ZIP Class LocationPlease select the location where you took your course:Santikos Casa BlancaSantikos EmbassyClass Date*When did you take the course? (If unknown, please estimate): MM slash DD slash YYYY Reason for AttendanceWhy did you take Defensive Driving on the above date? Ticket Dismissal Insurance Discount Education Court InformationPlease enter your court information as it appears on your citation or court issued documents: Reason for New Certificate*Please select the reason for your new certificate request: I have NOT received my certificate I received my certifcate, but it shows incorrect information I received my certifcate and it is correct, but I would like an additional copy Change(s)Please select what information requires a change (select all that apply): Name Address Date of Birth Driver's License Number Court Information Reason for Attendance Changes (Description)Please describe all necessary changes: Certificate Delivery*How would you like to receive your new certificate? Email (typically delivered within 24 hours) USPS First Class Mail (typically delivered in 7-10 business days) Email* Price Price: All new certificate requests made after 30 days from the original class date are subject to a processing fee. This fee also applies to all "additional copy" requests.Price Price: All "additional copy" requests are subject to a processing fee.Terms & Conditions* I agree.I agree to pay a $10 processing fee for each "additional copy" of my certificate or if my new certificate request is more than 30 days after my original class date.Total $0.00 Δ
